List the names, addresses, and phone numbers of anyone who may have been a witness.

Statement of observation by any witness(s):.

English
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at 1 866 756 4259.

Independent Medical Review (IMR) through the California Department of Managed Health Care
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-800-637-6453 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca/gov has complaint forms, IMR application forms and instructions online.
If you have questions or need assistance filing a grievance, you may contact Dental Health Services' Members Services at 503-281-1771. You may also file a complaint or seek assistance from the Oregon Insurance Division. Assistance is available:
By calling 503-948-77984 or the toll free message line at 888-877-4894;
By electronic mail at: cp.ins@state.or.us;
By writing to the Oregon Division of Insurance, Consumer Advocacy Unit at:
P.O. Box 14480; Salem, OR 97309-0405; or Through the Internet at http://www.insurance.oregon.gov/consumer/consumer.html

Dental Health Services complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, disability, or sex.

If you have questions or need assistance filing a grievance, you may contact Dental Health Services' Members Services at 800-637-6453. You may also file a complaint or seek assistance from the Washington State Office of Insurance Commissioner. Assistance is available:
By calling 800-562-6900 or;
By writing to the Washington State Office of Insurance Commissioner, Consumer Advocacy at:
P.O. Box 40255; Olympia, WA 98504-0255; or Through the Internet at www.insurance.wa.gov.

Dental Health Services complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, disability, or sex.

UTU-MTA

IMPORTANT: Can you read this? If not, we can have somebody help you read it. You may also be able to get this information written in your language. For free help, please call right away at 1-866-756-4259. Dental Health Services has a toll free TTY line 1-888-645-1257 for the hearing and speech impaired.